Cycle 1
Health 2026-01-29 · Fire 2026-01-29
2 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
8 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Middletown, IN
Waters Of Middletown Skilled Nursing Facility, The
4-star overall rating with 4-star inspections with 2 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
981 Beechwood Ave, Middletown, IN
(765) 354-2278
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
60
Certified beds
Average residents
28
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Infinity Healthcare Consulting
Operator or chain grouping
Approved since
1995-08-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
70 facilities
Chain averages 2 overall / 2 health / 2 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.37
Registered nurse staffing · state 0.66 · national 0.68
LPN hours / resident day
1.16
Licensed practical nurse staffing · state 0.77 · national 0.87
Aide hours / resident day
2.28
Nurse aide staffing · state 2.27 · national 2.35
Total nurse hours
3.81
All reported nurse hours · state 3.71 · national 3.89
Licensed hours
1.53
RN + LPN hours · state 1.44 · national 1.54
Weekend hours
3.43
Weekend nurse staffing · state 3.24 · national 3.43
Weekend RN hours
0.35
Weekend registered nurse coverage · state 0.45 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.30
CMS adjusted RN staffing hours
Adjusted total hours
3.07
CMS adjusted total nurse staffing hours
Case-mix index
1.70
Higher values indicate more complex resident acuity
RN turnover
100%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
69%
Annual nurse turnover · state 47% · national 46%
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.52% |
10.72%
1.2 pts better
|
No Different than the National Rate · Eligible stays 28 · Observed rate 0% · Lower 95% interval 5.98% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 24 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 0.93 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 16 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 20 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 40 |
| Staff flu vaccination coverage | 0% |
42%
42 pts worse
|
Numerator 0 · Denominator 41 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 94.7% |
93.6%
1.1 pts better
|
93.4%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q3 100.0% · Q4 91.3% · 4Q avg 94.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.3% |
3.8%
2.5 pts better
|
3.3%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q3 0.0% · Q4 0.0% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 52.1% |
24.6%
27.5 pts worse
|
11.4%
40.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q4 47.8% · 4Q avg 52.1% |
| Percentage of long-stay residents who lose too much weight | 7.0% |
5.6%
1.4 pts worse
|
5.4%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 7.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 21.1% |
23.5%
2.4 pts better
|
19.6%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 21.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 4.2% |
14.8%
10.6 pts better
|
16.7%
12.5 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 4.2% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 15.9% |
13.3%
2.6 pts worse
|
16.3%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 15.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 0.0% |
11.7%
11.7 pts better
|
14.9%
14.9 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.2% |
0.4%
0.8 pts worse
|
1.0%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q4 3.8% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
1.2%
1.2 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 27.0% |
24.2%
2.8 pts worse
|
19.8%
7.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q4 32.8% · 4Q avg 27.0% |
| Percentage of long-stay residents with pressure ulcers | 0.0% |
4.1%
4.1 pts better
|
5.1%
5.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 52.4% |
81.6%
29.2 pts worse
|
81.7%
29.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 50.0% · Q2 50.0% · Q3 50.0% · Q4 58.1% · 4Q avg 52.4% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.9% |
1.3%
2.6 pts worse
|
1.6%
2.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q3 4.8% · 4Q avg 3.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 45.7% |
79.0%
33.3 pts worse
|
79.7%
34 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 45.7% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-12-09 · Fire 2024-12-09
10 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2023-09-01 · Fire 2023-09-01
6 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
6 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2026-01-29
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Not marked corrected
F · Potential for more than minimal harm
2026-01-29
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Not marked corrected
F · Potential for more than minimal harm
2026-01-29
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Not marked corrected
F · Potential for more than minimal harm
2026-01-29
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Not marked corrected
E · Potential for more than minimal harm
2026-01-29
K300 · Egress Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Not marked corrected
E · Potential for more than minimal harm
2026-01-29
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Not marked corrected
E · Potential for more than minimal harm
2026-01-29
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Not marked corrected
D · Potential for more than minimal harm
2026-01-29
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Not marked corrected
F · Potential for more than minimal harm
2024-12-09
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-01-06
F · Potential for more than minimal harm
2024-12-09
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-01-06
E · Potential for more than minimal harm
2024-12-09
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-01-06
D · Potential for more than minimal harm
2024-12-09
K200 · Egress Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2025-01-06
F · Potential for more than minimal harm
2023-09-01
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2023-10-25
F · Potential for more than minimal harm
2023-09-01
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-10-25
F · Potential for more than minimal harm
2023-09-01
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2023-10-25
E · Potential for more than minimal harm
2023-09-01
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-10-25
E · Potential for more than minimal harm
2023-09-01
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-10-25
E · Potential for more than minimal harm
2023-09-01
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2023-10-25
Inspection history
Recent health citations
D · Potential for more than minimal harm
2026-01-29
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2026-02-20
D · Potential for more than minimal harm
2026-01-29
F740 · Quality of Life and Care Deficiencies
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2026-02-20
F · Potential for more than minimal harm
2024-12-09
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-12-30
E · Potential for more than minimal harm
2024-12-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-12-30
D · Potential for more than minimal harm
2024-12-09
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-12-30
D · Potential for more than minimal harm
2024-12-09
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-12-30
D · Potential for more than minimal harm
2024-12-09
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-12-30
D · Potential for more than minimal harm
2024-12-09
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2024-12-30
E · Potential for more than minimal harm
2024-04-26
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-05-20
D · Potential for more than minimal harm
2024-04-26
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-05-20
D · Potential for more than minimal harm
2024-04-26
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-05-20
D · Potential for more than minimal harm
2024-04-26
F741 · Quality of Life and Care Deficiencies
Health
Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents.
Corrected 2024-05-20
D · Potential for more than minimal harm
2023-10-12
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2023-10-31
D · Potential for more than minimal harm
2023-10-12
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-10-31
D · Potential for more than minimal harm
2023-09-01
F557 · Resident Rights Deficiencies
Health
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected 2023-09-20
D · Potential for more than minimal harm
2023-09-01
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-09-20
D · Potential for more than minimal harm
2023-09-01
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2023-09-20
D · Potential for more than minimal harm
2023-09-01
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-09-20
Penalties and ownership
What sits behind the stars
Ownership
Johnson Memorial Hospital
5% Or Greater Direct Ownership Interest · Organization
Berkhouse, Steven
Corporate Director · Individual
Berkhouse, Steven
Corporate Officer · Individual
Decola, Robert
W-2 Managing Employee · Individual
Dunkle, David
Operational/Managerial Control · Individual
Dunkle, David
Corporate Director · Individual
Dunkle, David
Corporate Officer · Individual
Jackman, Sarah
Contracted Managing Employee · Individual
The Waters Of Middletown Skilled Nursing Facility LLC
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
Middletown Nursing And Rehabilitation Center
Middletown, IN
5-star overall rating with 4-star inspections with 2 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
#2
Waters Of Chesterfield Skilled Nursing Facility
Chesterfield, IN
3-star overall rating with 3-star inspections with 6 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Envive Of Anderson
Anderson, IN
3-star overall rating with 3-star inspections with $8,390 in total fines with 5 recent health deficiencies with 14 fire-safety deficiencies in the latest cycle
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